Evaluation Research on Results-Based Financing An Annotated Bibliography of Health Science Literature on RBF Indicators for Reproductive , Maternal , Newborn , Child , and Adolescent Health

This annotated bibliography offers a critical review of peer-reviewed and gray literature published between 2002 and 2016 and relevant to indicators for the monitoring and evaluation of results-based financing (RBF) initiatives for reproductive maternal neonatal child and adolescent health (RMNCAH). Unlike a systematic review this annotated bibliography does not aim to be a comprehensive assessment of the research on RBF for health. Rather it seeks to describe the conceptual contribution and practical experiences of experts in using indicators to assess performance and quality throughout RMNCAH-focused RBF schemes. The review includes peer-reviewed articles toolkits technical briefs case studies and evaluation reports. Microsoft PowerPoint presentations posters and books are not included. Articles were identified via key informant interviews online database searches and website reviews. For Google Scholar and the PubMed databases search terms were indicators results based financing performance based financing performance based funding quality reproductive maternal neonatal child and adolescent health. Gray literature was identified through searches of the following regional multilateral and donor websites: RBFHealth World Bank World Health Organization BlueSquare United States Agency for International Development (USAID) USAID TRAction Project Salud Mesoamerica Initiative Pan American Health Organization the United Nations Children’s Fund and the USAID-funded MEASURE Evaluation. Review of the listed references of pertinent articles yielded additional resources.


INTRODUCTION
This annotated bibliography offers a critical review of peer-reviewed and gray literature, published between 2002 and 2016, and relevant to indicators for the monitoring and evaluation of results-based financing (RBF) initiatives for reproductive, maternal, neonatal, child, and adolescent health (RMNCAH).Unlike a systematic review, this annotated bibliography does not aim to be a comprehensive assessment of the research on RBF for health.Rather, it seeks to describe the conceptual contribution and practical experiences of experts in using indicators to assess performance and quality throughout RMNCAH-focused RBF schemes.This document outlines the protocol for the impact evaluation of the hospital improvement program.The evaluation will provide an estimate of the impact of the project and investigate the mechanism for success in a way that can provide general lessons about the quality of health care in low-income countries.The evaluation aims 1) to provide the best possible estimate of program impact and 2) to quantitatively describe the changes that took place within facilities as a result of the program.In particular, the impact evaluation focuses on the changes in human resources within the hospitals.As such, a three-period intensive evaluation of treated and matched comparison hospitals is used to see how services change in treated hospitals, as well as a continuous data collection effort to track the activities of individual health workers within treated hospitals.
Of particular interest in this evaluation is understanding how facilities met quality targets.Did they bring in new health workers with higher qualifications?Did they improve the knowledge or competence of their existing staff?Did they improve the availability of medicines and equipment so that the capacities of existing health workers were improved?Did they address the motivation of health workers so that individuals with the same competence and capacity were able to provide higher quality?And, if they did improve quality, did patients notice? 5. Brenner, S., Muula, A. S., Robyn, P. J., Bärnighausen, T., Sarker, M., Mathanga, D. P., ... & De Allegri, M. (2014).Design of an impact evaluation using a mixed methods model-an explanatory assessment of the effects of results-based financing mechanisms on maternal healthcare services in Malawi.BMC Health Services Research, 14(1), 1. Retrieved from http://bmchealthservres.biomedcentral.com/articles/10.1186/1472-6963-14-180

Summary
In this article, a study design is presented to evaluate the causal impact of providing supply-side performancebased financing incentives in combination with a demand-side cash transfer component on equitable access to and quality of maternal and neonatal healthcare services.This intervention is introduced to selected emergency obstetric care facilities and catchment area populations in four districts in Malawi.The study protocol is described and discussed with regard to the research aims, the local implementation context, and the rationale for selecting a mixed methods explanatory design with a quasi-experimental quantitative component.
The quantitative research component consists of a controlled pre-and post-test design with multiple post-test measurements.This allows the quantitative measurement of 'equitable access to healthcare services' at the community level and 'healthcare quality' at the health facility level.Guided by a theoretical framework of causal relationships, a number of input, process, and output indicators are determined to evaluate both intended and unintended effects of the intervention.Overall causal impact estimates will result from a difference-indifference analysis comparing selected indicators across intervention and control facilities/catchment populations over time.To further explain heterogeneity of quantitatively observed effects and to understand the experiential dimensions of financial incentives on clients and providers, a qualitative component is designed, in line with the overall explanatory mixed methods approach.This component consists of in-depth interviews and focus group discussions with providers, service user, non-users, and policy stakeholders.In this explanatory design comprehensive understanding of expected and unexpected effects of the intervention on both access and quality will emerge through careful triangulation at two levels: across multiple quantitative elements and across quantitative and qualitative elements.
Combining a traditional quasi-experimental controlled pre-and post-test design with an explanatory mixed methods model permits an additional assessment of organizational and behavioral changes affecting complex processes.Through this impact evaluation approach, the design will not only create robust evidence measures for the outcome of interest, but also generate insights on how and why the investigated interventions produce certain intended and unintended effects and allows for a more in-depth evaluation approach.care evaluation.This paper describes a strategy for identifying core process indicators for routine care and illustrates their usefulness in a field example.
An indicator selection strategy was first developed by combining epidemiological and programmatic aspects relevant to MNH in LMICs.Routine care process indicators, meeting the selection criteria were then identified by reviewing existing quality of care assessment protocols.These indicators were grouped into three categories based on their main function in addressing risk factors of maternal or neonatal complications.The indicator set was then tested in a study assessing MNH quality of clinical care in 33 health facilities in Malawi.
The strategy identified 51 routine care processes: 23 related to initial patient risk assessment, 17 to risk monitoring, 11 to risk prevention.During the clinical performance assessment a total of 82 cases were observed.Birth attendants' adherence to clinical standards was lowest in relation to risk monitoring processes.
In relation to major complications, routine care processes addressing fetal and newborn distress were performed relatively consistently, but there were major gaps in the performance of routine care processes addressing bleeding, infection, and pre-eclampsia risks.

Summary
Community health workers (CHWs) can play important roles in primary health care delivery, particularly in settings of health workforce shortages.However, little is known about CHWs' perceptions of barriers and motivations, as well as those of the beneficiaries of CHWs.In Rwanda, which faces a significant gap in human resources for health, the Ministry of Health expanded its community health programme beginning in 2007, eventually placing 4 trained CHWs in every village in the country by 2009.The aim of this study was to assess the capacity of CHWs and the factors affecting the efficiency and effectiveness of the CHW programme, as perceived by the CHWs and their beneficiaries.
As part of a larger report assessing CHWs in Rwanda, a cross-sectional descriptive study was conducted using focus group discussions (FGDs) to collect qualitative information regarding educational background, knowledge and practices of CHWs, and the benefits of community-based care as perceived by CHWs and household beneficiaries.A random sample of 108 CHWs and 36 beneficiaries was selected in 3 districts according to their food security level (low, middle and high).Qualitative and demographic data were analyzed.
CHWs were found to be closely involved in the community, and widely respected by the beneficiaries.Rwanda's community performance-based financing (cPBF) was an important incentive, but CHWs were also strongly motivated by community respect.The key challenges identified were an overwhelming workload, irregular trainings, and lack of sufficient supervision.

Summary
Performance-based incentives (PBIs) aim to counteract weak providers' performance in health systems of many developing countries by providing rewards that are directly linked to better health outcomes for mothers and their newborns.Translating funding into better health requires many actions by a large number of people.The actions span from community to the national level.While different forms of PBIs are being implemented in a number of countries to improve health outcomes, there has not been a systematic review of the evidence of their impact on the health of mothers and newborns.This paper analyzes and synthesizes the available evidence from published studies on the impact of supply-side PBIs on the quantity and quality of health services for mothers and newborns.This paper reviews evidence from published and gray literature that spans PBI for public-sector facilities, PBI in social insurance reforms, and PBI in NGO contracting.Some initiatives focus on safe deliveries, and others reward a broader package of results that include deliveries.The Evidence Review Team that focused on supply-side incentives for the US Government Evidence Summit on Enhancing Provision and Use of Maternal Health Services through Financial Incentives reviewed published research reports and papers and added studies from additional gray literature which were deemed relevant.After collecting and reviewing 17 documents, nine studies were included in this review, three of which used beforeafter designs; four included comparison or control groups; one applied econometric methods to a five-year time series; and one reported results from a large-scale impact evaluation with randomly-assigned intervention and Evaluation Research on RBF: An Annotated Bibliography 9 control facilities.The available evidence suggests that incentives that reward providers for institutional deliveries result in an increase in the number of institutional deliveries.There is some evidence that the content of antenatal care can improve with PBI.No direct evidence on the impact of PBI on neonatal health services or on mortality of mothers and newborns was found, although intention of the study was not to document impact on mortality.A number of studies describe approaches to rewarding quality as well as increases in the quantities of services provided, although how quality is defined and monitored is not always clear.Because incentives exist in all health systems, considering how to align the incentives of the many health workers and their supervisors so that they focus efforts on achieving health goals for mothers and newborns is critical if the health system is to perform more effectively and efficiently.A wide range of PBI models is being developed and tested, and there is still much to learn about what works best.Future studies should include a larger focus on rewarding quality and measuring its impact.Finally, more qualitative research to better understand PBI implementation and how various incentive models function in different settings is needed to help practitioners refine and improve their programmes.

Summary
Performance-based financing (PBF) is an increasingly adopted strategy in low and middle-income countries.PBF pilot projects started in Burundi in 2006, at the same time when a national policy removed user fees for pregnant women and children below 5 years old.As part of the methods, PBF was gradually extended to the 17 provinces of the country.This roll-out and data from the national health information system were exploited to assess the impact of PBF on the use of health-care services.
Results found that PBF is associated with an increase in the number of anti-tetanus vaccination of pregnant women (around þ20 percentage points in target population, P < 0.10).Non-robust positive effects are also found on institutional deliveries and prenatal consultations.Changes in outpatient visits, postnatal visits and children vaccinations are not significantly correlated with PBF.It is also found that more qualified nurses headed to PBF-supported provinces.The limited quality of the data and the restricted size of the sample have to be taken into account when interpreting these results.Health facility-level figures from PBF-supported provinces show that most indicators but those relative to preventive care are growing through time.
The dataset does not include indicators of the quality of care and does not allow to assess whether changes associated with PBF are resource-driven or due to the incentive mechanism itself.The results are largely consistent with other impact evaluations conducted in Burundi and Rwanda.The fact that PBF is mostly associated with positive changes in the use of services that became free suggests an important interaction effect between the two strategies.A possible explanation is that the removal of user fees increases accessibility to health care and acts on the demand side while PBF gives medical staffs incentives for improving the provision of services.More empirical research is needed to understand the sustainability of (the incentive mechanism of) PBF and the interaction between PBF and other health policies.

Summary
The continuum of care has become a rallying call to reduce the yearly toll of half a million maternal deaths, 4 million neonatal deaths, and 6 million child deaths.The continuum for maternal, newborn, and child health usually refers to continuity of individual care.Continuity of care is necessary throughout the lifecycle (adolescence, pregnancy, childbirth, the postnatal period, and childhood) and also between places of caregiving (including households and communities, outpatient and outreach services, and clinical-care settings).A population-level or public-health framework is defined based on integrated service delivery throughout the lifecycle, and propose eight packages to promote health for mothers, babies, and children.These packages can be used to deliver more than 190 separate interventions, which would be difficult to scale up one by one.The packages encompass three which are delivered through clinical care (reproductive health, obstetric care, and care of sick newborn babies and children); four through outpatient and outreach services (reproductive health, antenatal care, postnatal care and child health services); and one through integrated family and community care throughout the lifecycle.Mothers and babies are at high risk in the first days after birth, and the lack of a defined postnatal care package is an important gap, which also contributes to discontinuity between maternal and child health programmes.Similarly, because the family and community package tends not to be regarded as part of the health system, few countries have made systematic efforts to scale it up or integrate it with other levels of care.Building the continuum of care for maternal, newborn, and child health with these packages will need effectiveness trials in various settings; policy support for integration; investment to strengthen health systems; and results-based operational management, especially at district level.

Summary
Quality of care is emerging as an important concern for low-and middle-income countries working to expand and improve coverage.However, there is limited systematic, large-scale empirical guidance to inform policy design.This study operationalized indicators for six dimensions of quality of care that are captured in currently available, standardized Service Provision Assessments.These measures were implemented to assess the levels and heterogeneity of antenatal care in Kenya.Using the indicator mix, it was found that performance is low overall and that there is substantial variation across provinces, management authority and facility type.Overall, facilities performed highest in the dimensions of efficiency and acceptability/patient-centeredness, and lowest on effectiveness and accessibility.Public facilities generally performed worse or similarly to private or faithbased facilities.The authors of this study illustrate how these data and methods can provide readily-available, low cost decision support for policy.

Summary
Health has improved markedly in Mesoamerica, the region consisting of southern Mexico and Central America, over the past decade.Despite this progress, there remain substantial inequalities in health outcomes, access, and quality of medical care between and within countries.Poor, indigenous, and rural populations have considerably worse health indicators than national or regional averages.In an effort to address these health inequalities, the Salud Mesoamérica 2015 Initiative (SM2015), a results-based financing initiative, was established.
For each of the eight participating countries, health targets were set to measure the progress of improvements in maternal and child health produced by the Initiative.To establish a baseline, censuses of 90,000 households were conducted, 20,225 household interviews completed, and 479 health facilities surveyed in the poorest areas of Mesoamerica.Pairing health facility and household surveys allowed for linking barriers to care and health outcomes with health system infrastructure components and quality of health services.
Indicators varied significantly within and between countries.Anemia was most prevalent in Panama and least prevalent in Honduras.Anemia varied by age, with the highest levels observed among children aged 0 to 11 months in all settings.Belize had the highest proportion of institutional deliveries (99%), while Guatemala had the lowest (24%).The proportion of women with four antenatal care visits with a skilled attendant was highest in El Salvador (90%) and the lowest in Guatemala (20%).Availability of contraceptives also varied.The availability of condoms ranged from 83% in Nicaragua to 97% in Honduras.Oral contraceptive pills and injectable contraceptives were available in just 75% of facilities in Panama.IUDs were observed in only 21.5% of facilities surveyed in El Salvador.
These data provide a baseline of much-needed information for evidence-based action on health throughout Mesoamerica.Baseline estimates reflect large disparities in health indicators within and between countries and will facilitate the evaluation of interventions and investments deployed in the region over the next three to five years.SM2015's innovative monitoring and evaluation framework will allow health officials with limited resources to identify and target areas of greatest need.

Summary
As part of a growing focus on the effectiveness of development assistance from the World Bank and other agencies, new efforts are being made to relate development finance more closely to outcomes achieved rather than to inputs used, through the results-based financing approach.The authors provide a framework for analyzing the operational dimensions of results-based financing, including the conditions that suit this approach, and how best to define, measure, and report results.Some of the early World Bank experience with this approach is reviewed.Noting that this approach is as yet not fully tested, evaluative issues for future research are suggested while highlighting strengths and challenges in the range of techniques adopted so far.This study undertook a critical appraisal of selected evaluations of RBF schemes in the health sector in low and middle-income countries (LMIC).In addition, key informants were interviewed to identify literature relevant to the use of RBF in the health sector in LMIC, key examples, evaluations, and other key informants.
The use of RBF in LMIC has commonly been a part of a package that may include increased funding, technical support, training, changes in management, and new information systems.It is not possible to disentangle the effects of financial incentives as one element of RBF schemes, and there is very limited evidence of RBF per se having an effect.RBF schemes can have unintended effects.
When RBF schemes are used, they should be designed carefully, including the level at which they are targeted, the choice of targets and indicators, the type and magnitude of incentives, the proportion of financing that is paid based on results, and the ancillary components of the scheme.For RBF to be effective, it must be part of an appropriate package of interventions, and technical capacity or support must be available.RBF schemes should be monitored for possible unintended effects and evaluated using rigorous study designs.

Summary
In some low-income countries such as Cambodia and Rwanda, experimental performance-based payment systems have led to rapid improvements in access to health care and the quality of that care.Under this type of payment scheme, funders-including foreign governments and international aid programs-subsidize local health care providers for achieving certain benchmarks.The benchmarks can include such measures as child immunizations or childbirth in a health facility.In this article, the results of a performance-based payment experiment conducted in the Democratic Republic of Congo are reported.The Democratic Republic of Congo is one of the poorest countries in the world and has an extremely high level of child and maternal mortality.This study found that providing performance-based subsidies resulted in lower direct payments to health facilities for patients, who received comparable or better services and quality of care than those provided at a control group of facilities that were not financed in this way.The disparity occurred despite the fact that the districts receiving performance-based subsidies received external foreign assistance of approximately $2 per capita per year, compared to the $9-$12 in external assistance received by the control districts.The experiment also revealed that performance-based financing mechanisms can be effective even in a troubled nation such as the Democratic Republic of Congo.

Summary
Governments of low-and middle-income countries (LMICs) are widely implementing performance-based financing (PBF) to improve healthcare services.However, it is unclear whether PBF provides good value for money compared to status quo or other interventions aimed at strengthening the healthcare system in LMICs.The objective of this systematic review is to identify and synthesize the existing literature that examines whether PBF represents an efficient manner of investing resources.PBF was considered to be efficient when improved care quality or quantity was achieved with equal or lower costs, or alternatively, when the same quality of care was achieved using less financial resources.A manual search of the reference lists of two recent systematic reviews on economic evaluations of PBF was conducted to identify articles that met our inclusion and exclusion criteria.Subsequently, a search strategy was developed with the help of a librarian.The following databases and search engines were used: PubMed, EconLit, Google Scholar and Google.Experts on economic evaluations were consulted for validation of the selected studies.A total of seven articles from five LMICs were selected for this review.The overall strength of the evidence was found to be weak.None of the articles were full economic evaluations; they did not make clear connections between the costs and effects of PBF.Only one study reported using a randomized controlled trial, but issues with the randomization procedure were reported.Important alternative interventions to strengthen the capacities of the healthcare system have not been considered.Few studies examined the costs and consequences of PBF in the long term.Important costs and consequences were omitted from the evaluations.

Summary
Results-based financing (RBF) is an innovative approach to health system financing which pays providers for verified outputs.In July 2011, through a World Bank grant, Zimbabwe commenced an RBF project to improve utilization of quality maternal, neonatal and child health (MNCH) services.This article discusses its early results.
A statistical analysis of intervention districts and control districts shows that RBF districts demonstrate higher increases in utilization levels for the MNCH services than control districts.Month-on-month growth rates for antenatal care, perinatal referrals and growth monitoring are statistically significant after the intervention, whilst they were not before the intervention and no significant trend was found in control districts.Qualitative study provides insight in the mechanisms through which RBF contributed to better performance: the use of contracts, increased autonomy of health facilities, increased community involvement, intrinsic motivation of health-care workers, existence of a reliable health information system, abolishment of user fees, improved supervision of health facilities, separation of functions, and the Government of Zimbabwe's results-based management (RBM) policy 22. Witter, S., Toonen, J., Meessen, B., Kagubare, J., Fritsche, G., & Vaughan, K. ( 2013).Performance-based financing as a health system reform: Mapping the key dimensions for monitoring and evaluation.BMC Health Services Research, 13(1), 1. Retrieved from http://bmchealthservres.biomedcentral.com/articles/10.1186/1472-6963-13-367

Summary
Performance-based financing is increasingly being applied in a variety of contexts, with the expectation that it can improve the performance of health systems.However, while there is a growing literature on implementation issues and effects on outputs, there has been relatively little focus on interactions between PBF and health systems and how these should be studied.This paper aims to contribute to filling that gap by developing a framework for assessing the interactions between PBF and health systems, focusing on low and middle income countries.In doing so, it elaborates a general framework for monitoring and evaluating health system reforms in general.
This paper is based on an exploratory literature review and on the work of a group of academics and PBF practitioners.The group developed ideas for the monitoring and evaluation framework through exchange of emails and working documents.Ideas were further refined through discussion at the Health Systems Research symposium in Beijing in October 2012, through comments from members of the online PBF Community of Practice and Beijing participants, and through discussion with PBF experts in Bergen in June 2013.
The paper starts with a discussion of definitions, to clarify the core concept of PBF and how the different terms are used.It then develops a framework for monitoring its interactions with the health system, structured around five domains of context, the development process, design, implementation and effects.Some of the key questions for monitoring and evaluation are highlighted, and a systematic approach to monitoring effects proposed, structured according to the health system pillars, but also according to inputs, processes and outputs.
The paper lays out a broad framework within which indicators can be prioritised for monitoring and evaluation of PBF or other health system reforms.It highlights the dynamic linkages between the domains and the different pillars.All of these are also framed within inter-sectoral and wider societal contexts.It highlights the importance of differentiating short term and long term effects, and also effects (intended and unintended) at different levels of the health system, and for different sectors and areas of the country.Outstanding work will include using and refining the framework and agreeing on the most important hypotheses to test using it, in relation to PBF but also other purchasing and provider payment reforms, as well as appropriate research methods to use for this task.

Summary
To strengthen Haiti's primary health care (PHC) system, the country first piloted performance-based financing (PBF) in 1999 and subsequently expanded the approach to most internationally funded non-government organizations.PBF complements support (training and technical assistance).This study evaluates (a) the separate impact of PBF and international support on PHC's service delivery; (b) the combined impact of PBF and technical assistance on PHC's service delivery; and (c) the costs of PBF implementation in Haiti.To minimize the risk of facilities neglecting potential non-incentivized services, the incentivized indicators were randomly chosen at the end of each year.Quantities of key services were obtained from four departments for 217 health centres (15 with PBF and 202 without) from 2008 through 2010, computed quarterly growth rates and analysed the results using a difference-in-differences approach by comparing the growth of incentivized and non-incentivized services between PBF and non-PBF facilities.To interpret the statistical analyses, staff in four facilities were also interviewed.Whereas international support added 39% to base costs of PHC, incentive payments added only 6%.Support alone increased the quantities of PHC services over 3 years by 35% (2.7%/quarter).However, support plus incentives increased these amounts by 87% over 3 years (5.7%/quarter) compared with facilities with neither input.Incentives alone were associated with a net 39% increase over this period, and more than doubled the growth of services (P < 0.05).Interview findings found no adverse impacts and, in fact, indicated beneficial impacts on quality.Incentives proved to be a relatively inexpensive, well accepted and very effective complement to support, suggesting that a small amount of money, strategically used, can substantially improve PHC.Haiti's experience, after more than a decade of use, indicates that incentives are an effective tool to strengthen PHC.
incentive to provide more or better care.This has led to an enquiry by donors and implementing agencies on how to support public health systems through adoption of reward or incentive based approaches.There are varied definitions used to describe the levels of incentives and performance rewards, whether organizational which includes: RBF; "results based performance", P4P; (payment for performance) and PBF; performance based financing.For the purpose of this review, "performance based financing" will be adopted as the working terminology.Performance Based Financing (PBF) is predicated on the assumption that linking incentives to performance will contribute to improvement in access, quality and equity of service outputs.In some instances, NGOs are fund holders, who in turn establish performance based contracts with district level administrations or with other non-government entities.In other countries (Tanzania and Zambia for example) the fund holder is a government entity that channels the NGO money while Rwanda now has a government fund holder.The contracts in all cases employ a business plan whereby health worker incentives are tied to performance, based on an agreed set of indicators.PBF is currently viewed as a promising and innovative strategy to tackle issues related to improved access, utilization, and provider performance2.In this literature review, incentive based approaches adopted in developing countries over the past decade will be explored, with a focus on the contribution of Performance Based Financing (PBF) to productivity, quality of health care and ultimately on the performance of health providers.Section One outlines the various definitions that are applicable to a wide range of performance based incentive schemes.Section Two reviews the institutional approaches that have been deployed by NGOs in collaboration with country level stakeholders, with a specific focus on the costs of introducing PBF using diverse operational approaches.Section Three explores the results that have been reported including both quantitative and qualitative effects on health service delivery and human resources.Section Four identifies the monitoring and evaluation tools that have been used to measure the results of PBF.Section Five offers a concluding summary with a proposed research agenda for future work.

Summary
This toolkit addresses the questions what and why, while focusing on the answer to how it can be done.The toolkit is pervaded by answers to the first question, while explaining the "how to": the process, the planning, the design, and the implementation of PBF schemes.It is written and reviewed by practitioners who have experimented with various methods and who have designed, implemented, witnessed, and evaluated its effects.Methods and approaches in PBF evolve continuously.Even though the toolkit provides guidance based on experience, the experience itself is based on trial and error and constant testing, assessing, and reassessing.This approach is why the toolkit is not meant as a final product but, rather, conceived as an organized and structured one-stop shop for the forms, tools, spreadsheets, contracts, terms of reference, performance frameworks, and other documents to implement PBF approaches in low-and lower-middle-income countries.The toolkit is written by implementers for implementers and attempts to capture the current state of affairs and best practices, while attempting to stay abreast by updating the methods, experiences, and tools used.
The introduction to the toolkit includes a short history of PBF, a discussion of terminology, and a simplified example of what PBF looks like for a health center.Most chapters contain a mix of conceptual information and practical "how to" guidance.The grouping was categorized as first, elements that consider facility-level phenomena, such as services, quality, setting of the fees, equity, and autonomy, and second, a collection of life year through the program was $814, which is highly cost-effective compared with Argentina's $6,075 gross domestic product per capita over this period.Although there are small negative spillover effects on prenatal care utilization of non-beneficiary populations in clinics covered by Plan Nacer, no spillover is found on their birth outcomes.9. Grittner, A. M. (2013

Summary
This paper contributes to investigating the experiences made with results-based funding as well as the unanswered question regarding the potential of results-based approaches to make development aid and domestic funds more effective and efficient.It focuses on performance-based financing (PBF), which is a type of results-based financing (RBF), as opposed to results-based aid (RBA).The paper reviews the targeting mechanisms, incentive structure, effectiveness and the efficiency of performance-based financing in the health sector through study of the experiences and data from PBF programmes in 13 developing countries in Africa, Asia and South America.It was found that from the 13 experiences studied in the present paper, five targeted explicitly poor areas or households, whereas seven had the more general goal of increasing access to and quality of basic healthcare services.When setting monetary incentives for good performance, PBF tends to focus on outputs rather than on health outcomes, and on quantity rather than on quality.Most schemes set target indicators at the level of healthcare supply or healthcare coverage, but at least 5 out of the 13 schemes studied also used indicators capturing impact.In contrast, only three programmes set performance targets for good quality of healthcare delivery.
The available qualitative and quantitative evaluations of the schemes studied in this paper suggest that PBF may be more effective in improving healthcare supply and healthcare coverage than other funding schemes.This applies mainly to the targeted indicators.However, there is little evidence that these improvements in health outputs and outcomes are achieved through the results orientation of the programmes as opposed to additional funding and other contextual factors, because rigorous impact evaluations are still lacking.Evidence of the impact of PBF on the quality of healthcare delivery and on the efficiency of PBF is also insufficient.Even though there is some suggestive evidence that PBF may be more cost-effective than other funding schemes, a lack of crucial financial information makes it difficult to evaluate the efficiency of PBF.
All in all, better and more monitoring of experiences as well as more research are needed in order to evaluate the potential of PBF in particular, and of RBF in general.In the future research agenda, efforts should particularly focus on investigating the incentive structure of RBF more thoroughly -including non-monetary and perverse incentives -, on evaluating the effectiveness and efficiency of schemes more rigorously, and on studying the long-term effects of RBF.
on distilling the evidence and experiences from the countries studied, thereby presenting a meta-analysis of the results and providing lessons that may incite the partners involved to adapt their policies and practice.Overall, this study shows that PBF is a promising approach, but that more research and critical reflection are necessary to enable PBF to continue to adapt to each context and to evaluate if it is indeed the most effective approach for delivery of improved health services.The methodology of introducing the PBF approach requires operational research and field-testing of different approaches to understand which one leads to the sustainable and successful results.The research agenda defines the priority areas that call for more evidence based analysis in order to strengthen the approach while ensuring that it becomes embedded within the health system.The DRC has selected Results-Based Financing (RBF) in order to reach its goals for improving health system performance.In compliance with the National Health Development Plan (NHDP 2011(NHDP -2015)), and USAID's objectives, USAID's Integrated Health Project in the DRC (IHP) has selected RBF as a strategy that will allow it to improve the quality, access and availability of the Minimum package of activities (MPA) and Complementary package of activities (CPA) services in the target Health Zones.The WHO's 2008 World Health Report recommended that primary health care be improved through four reforms (i.e.reform of services, reform of universal coverage, reform of leadership and reform of public policy) which correspond to those that were undertaken in the DRC through the Health Systems Strengthening Strategy (HSSS).The HSSS constitutes the health sector's contribution to effective and efficient progress toward reaching the Millennium Development Goals (MDGs) and these reforms relate simultaneously to governance, health financing and services.Since 2006, implementation of HSSS has resulted in best practices that need to be capitalized on, but it has also highlighted various problems that are of great concern to the government, represented by the Ministry of Public Health (MSP).

United States
This manual relies on the HSSS, the NHDP, national directives for implementation of the RBF, the Ministry of Health's RBF operationalization guide, MSH's RBF experiences worldwide and the experiences of other RBF stakeholders in the DRC.It gives greater attention to the operational and procedural aspects, in a straightforward and practical style, focusing on IHP's specific context.The manual is intended for the various RBF players, in order to facilitate the implementation of RBF in the IHP project to help improve quality, access and management of health services.
23. Zeng, W., Cros, M., Wright, K. D., & Shepard, D. S. (2012).Impact of performance-based financing on primary health care services in Haiti.Health Policy and Planning, czs099.Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/23107831 Agency for International Development (August 2014).Integrated Health project (IHP) Results-based Financing Program.The Democratic republic of Congo.IHP RBF Manual (Draft)SummaryThis manual seeks to address the concerns of other reference works and documents on RBF, which often tend to be theoretical or general in nature, and are written for health funding program managers and designers.It is the result of internal work to design the IHP RBF model, discussions with the appropriate entities in the Ministry of Health, USAID and other stakeholders who work on RBF in the Democratic Republic of the Congo (DRC).
Meessen, B., Soucat, A., & Sekabaraga, C. (2011).Performance-based financing: Just a donor fad or a catalyst towards comprehensive health-care reform?Bulletin of the World Health Organization, 89(2), 153-156.Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3040374/SummaryPerformance-basedfinancing is generating a heated debate.Some suggest that it may be a donor fad with limited potential to improve service delivery.Most of its critics view it solely as a provider payment mechanism.The authors' experience is that performance-based financing can catalyze comprehensive reforms and help address structural problems of public health services, such as low responsiveness, inefficiency and inequity.The emergence of a performance-based financing movement in Africa suggests that it may contribute to profoundly transforming the public sectors of low-income countries.14.Mokdad, A. H., Colson, K. E., Zúñiga-Brenes, P., Ríos-Zertuche, D., Palmisano, E. B., Alfaro-Porras, E., ...
Evaluation Research on RBF: An Annotated Bibliography 11 13.& Gillespie, C. W. (2015).Salud Mesoamérica 2015 Initiative: Design, implementation, and baseline findings.Population Health Metrics, 13(1), 1. Retrieved from https://pophealthmetrics.biomedcentral.com/articles/10.1186/s12963-015-0034-4 15. O'Brien, T., & Kanbur, R. (2014).The operational dimensions of results-based financing.Public Administration and Development, 34(5), 345-358.Retrieved from http://onlinelibrary.wiley.com/doi/10.1002/pad.1698/abstract 17. Pronyk, P. M.,Nemser, B., Maliqi, B., Springstubb, N., Sera, D., Karimov, R., ... & Leads, U. A. (2016).The UN Commission on Life Saving Commodities 3 years on: Global progress update and results of a multicountry assessment.The Lancet Global Health, 4(4), e276-e286.Retrieved from http://www.thelancet.com/journals/langlo/article/PIIS2214-109X(16)00046-2/abstractSummary In September, 2012, the UN Commission on Life Saving Commodities (UNCoLSC) outlined a plan to expand availability and access to 13 lifesaving commodities.Global and country progress was profiled against these recommendations between 2012 and 2015.For 12 countries in sub-Saharan Africa that were off -track to achieve the Millennium Development Goals for maternal and child survival, key documents were reviewed and referenced data, and interviews conducted with ministry staff and partners to assess the status of the UNCoLSC recommendations.The RMNCH fund provided short-term catalytic financing to support country plans to advance the commodity agenda, with activities coded by UNCoLSC recommendation.The network of technical resource teams identified, addressed, and monitored progress against cross-cutting commodity-related challenges that needed coordinated global action.and also to point out relevant issues and structure findings, a comprehensive analytical framework was used, based on eight dimensions.The review inter alia indicates that PBF is generally welcomed by the main actors (patients, health workers and health managers), yet what PBF actually entails is less straightforward.More research is needed on the exact mechanisms through which not only incentives but also ancillary components operate.This knowledge is essential if we really want to appreciate the effectiveness, desirability and appropriate format of PBF as one of the possible answers to the challenges in the health sector of low-and lower middleincome countries.A clear definition of the research constructs is a primordial starting point for such research.
In 2014 and 2015, child and maternal health commodities had fewer bottlenecks than reproductive and neonatal commodities.Common bottlenecks included regulatory challenges (ten of 12 countries); poor quality assurance (11 of 12 countries); insufficient staff training (more than half of facilities on average); and weak supply chains systems (11 of 12 countries), with stock-outs of priority commodities in about 40% of facilities on average.The RMNCH fund committed US$175•7 million to 19 countries to support strategies addressing crucial gaps.$68•2 million (39•0%) of the funds supported systems-strengthening interventions with the remainder split across reproductive, maternal, newborn, and child health.Health worker training ($88•6 million, 50•4%), supply chain ($53•3 million, 30•0%), and demand generation ($21•1 million, 12•0%) were the major topics of focus.All priority commodities are now listed in the WHO Essential Medicines List; appropriate price reductions were secured; quality manufacturing was improved; a fast-track registration mechanism for prequalified products was established; and methods were developed for advocacy, quantification, demand generation, supply chain, and provider training.Slower progress was evident around regulatory harmonisation and quality assurance.Much work is needed to achieve full implementation of the UNCoLSC recommendations.Coordinated efforts to secure price reductions beyond the 13 commodities and improve regulatory efficiency, quality, and supply chains are still needed alongside broader dissemination of work products.knowledge on how PBF works, set out what still needs to be investigated and formulate recommendations for researchers and policymakers from donor and recipient countries alike.Drawing on an extensive systematic literature review of peer-reviewed journals, 35 relevant articles were analyzed.For guidance through this variety of studies, Few LMICs are represented in the literature, despite wide implementation.Lastly, most articles had at least one author employed by an organization involved in the implementation of PBF, thereby resulting in potential conflicts of interest.Stronger empirical evidence on whether PBF represents good value for money in LMICs is needed.21. van de Looij, F., Mureyi, D., Sisimayi, C., Koot, J., Manangazira, P., & Musuka, N. (2015).Early evidence from results-based financing in rural Zimbabwe.African Health Monitor.Issue 20.Special Issue on Universal Health Coverage.Retrieved from http://www.aho.afro.who.int/en/ahm/issue/20/articles/early-evidenceresults-based-financing-rural-zimbabwe This series of Title II Generic Indicator Guides has been developed by the Food and Nutrition Technical Assistance (FANTA) Project, and its predecessor projects (LINKAGES and IMPACT), as part of USAID's support to develop monitoring and evaluation systems for use in Title II programs.This guide provides information on the Anthropometric Impact Indicators and the Annual Monitoring Indicators for Maternal and Child Health/Child Survival (MCH/CS) and income-related Title II activities, a subset of the P.L. 480 Title II Generic Performance Indicators for Development Activities.The guide draws extensively from materials from the Anthropometry Resource Center, funded by the FAO/SADC project GCP/RAF/284/NET, Development of a Regional Food Security and Nutrition Information System, particularly the UN publication, How to Weigh and Measure Children: Assessing the Nutritional Status of Young Children in Household Surveys; and the WHO publication, Physical Status: The Use and Interpretation of Anthropometry.It is intended to provide the technical basis for the indicators and the recommended method for collecting, analyzing and reporting on the indicators.5. Eichler, R. (2006).Can "pay for performance" increase utilization by the poor and improve the quality of health services.Background papers for the Working Group on Performance Based Incentives.Washington, DC: Center for Global Development.Retrieved from http://www.hrhresourcecenter.org/node/506Summary This paper was prepared as background for the Working Group on Performance Based Incentives and begins by defining and describing "pay-for-performance (P4P)" approaches designed for consumers, individual health care providers, service delivery institutions, and subnational levels of countries.The focus is on demand-and supply-side financial and material (examples: food, travel vouchers) incentives that can be used to improve utilization and quality of ambulatory health care services, especially for the poor, including those interventions that link payment or material goods to indicators of performance (e.g.increased immunization coverage) or defined actions (e.g.TB patient presents to take medicine) that are closely correlated with improved health outcomes.Not included are approaches that transfer funds or goods to consumers or providers in ways that are not conditional on some measurable indicator of performance as well as other interventions aimed at improving performance such as provider training or health education.The paper also presents evidence of two basic, related problems: (1) health service under-utilization by the poor; and (2) substandard quality of services available to the poor.It also discusses determinants of demand and supply and principal agent theory, the relationship among elements of health systems, and the links between those elements and P4P applications, suggesting a framework for use in the evaluation and categorization of P4P interventions.Brief descriptions of a selected sample of P4P cases are also presented in the Annex.The paper concludes by providing broad unanswered questions that constitute a possible agenda that the working group could address.
). Results-based financing.Evidence from performance-based financing in the health sector.Bonn, Federal Republic of Germany: German Development Institute.Retrieved from http://www.oecd.org/development/peer-reviews/Results-based-financing.pdf